[Recorded by Electronic Apparatus]
Tuesday, December 12, 1995
.0909 
[English]
The Chairman: We're a little thin this morning. I didn't know the Christmas parties had begun, but something has begun. However, we do have enough members to receive evidence, which is what we're doing this morning. We're not going to make any earth-shattering decisions, but we can receive evidence provided we have three, and we do have five right now.
Mrs. Dalphond-Guiral (Laval Centre): I represent two.
The Chairman: In my mind you always represent two.
We'll proceed because we have three sets of witnesses and we may have a complication soon after 10 a.m. There's likely going to be a vote, and we'll deal with that when the time comes.
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First of all, from the Canadian Public Health Association we have two witnesses. I'm assuming throughout this whole piece that the witnesses know why they're here, so I won't state each time what our assignment is.
We're glad to have you. Would somebody start talking? You may want to introduce yourself and your colleague and then make a statement, but give us a little time to ask some questions.
Ms Marianne Stewart (Chair, Child Health Program, Canadian Public Health Association): I'm Marianne Stewart. I'm here representing the Canadian Public Health Association. I'm the chairman of the working group on child health. I'm also the manager of community health services in the Capital Health Authority in Edmonton, Alberta.
Ms Kathryn Tregunna (Senior Program Officer, Canadian Public Health Association): My name is Kathryn Tregunna. I'm the senior program officer at the Canadian Public Health Association. I'm responsible for national programs and policy development.
Ms Stewart: I'll begin by saying I'm delighted to be here. I will be providing a brief background about the Canadian Public Health Association, and then I will discuss the projects CPHA has undertaken within the child health program.
The Canadian Public Health Association is a national, independent, not-for-profit, voluntary association. Incorporated in 1912, CPHA represents over 25 health disciplines and the general public.
CPHA's members believe in universal and equitable access to the basic conditions that are necessary to achieve health for all Canadians. CPHA understands that the determinants of health include physical, social, mental, emotional, spiritual, and environmental factors. These determinants include the conditions required for healthy children.
CPHA's mission is to constitute a special national resource in Canada that advocates for the improvement and maintenance of personal and community health according to the public health principles of disease prevention, health promotion and protection, and healthy public policy.
Over the years, CPHA has advocated for health goals for the whole population. CPHA has also been active in the health of children. The project Perspectives on Health Promotion has identified children and families as a priority group for action. CPHA's child health program is comprised of two projects: Child Health Goals, a cross-country consultation on a national vision and goals for child and youth health in Canada; and the Child Health Record Project.
Beginning in 1991 and working together with a number of other national organizations and child health experts, CPHA worked with Health Canada on the development of a discussion paper called ``A Vision of Health for Children and Youth in Canada''. The vision document includes a vision statement, a mission statement, and six goals for child and youth health. The handout contains the draft mission's statement and goals. I believe that was handed out to you.
The paper was released in 1993, beginning a three-part consultation process between the community, which CPHA was responsible for coordinating, representatives of aboriginal organizations, and representatives of provincial and territorial governments. CPHA was pleased to receive funding to lead the community portion of the goals consultation process. CPHA worked in partnership with provincial and territorial public health associations to plan and host these consultations.
The goals of the process were to increase awareness of health challenges facing children and youth; identify areas of agreement and disagreement on the vision, goals, and priority issues; explore links between national, provincial, territorial, and community goal-setting exercises in order to support an integrated approach to preventing and responding to child health concerns; exchange practical ideas; identify successes and achievements to date; and recommend further action.
Over 500 Canadians participated in discussions that were held in each of the provinces and territories in the spring and fall of 1994. Participants in the discussions included youths and parents, representatives from aboriginal communities, multicultural groups, anti-poverty groups, and people from the health, social services, education, justice, and recreation sectors.
A video called Kids Talk and Videotape was shown to most participants. The candid comments made by children and youths in the video about matters that affect their health added an important dimension to the discussions.
Despite the diversity that exists in this country, common themes, issues, and suggestions emerged through the consultation process. These themes are discussed in this summary report entitled A Cross-Country Consultation on a National Vision and Goals for Child and Youth Health in Canada and summarized on page 4 of the executive summary. Again, I believe you have that with you.
There were several main themes consistent across the country. The first one is that there was genuine support across the country for the draft vision and goals, particularly in their consideration of the broad determinants of health.
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The second is meaningful involvement. Of all the goals, participants in the consultations from across the country gave their strongest support to the first goal, the meaningful involvement of children and youth. The Kids Talk and Videotape video I referred to earlier is an exemplary method of bringing the voices of children to any table in a meaningful and powerful way. I suggest you see it.
Impact of poverty. Participants were also concerned about the impact of poverty on child and youth health. There was agreement that poverty is not just a lack of money. Poverty, unemployment, and economic insecurity threaten the social, emotional, and spiritual health of families and communities and deny equal life chances to children. The individuals who attended the consultation meetings said meeting the basic needs of poor families, particularly aboriginal families, and preventing modest-income families from slipping into poverty, should be a top priority for policy action.
The importance of families. Participants in almost all the consultations indicated there is a need to recognize the diversity of family types that exist today and that all forms of families should be respected. Participants stated that families are very important and should be included in discussions of child and youth health.
On to the recommendations.
Based on the outcome of the public consultations, CPHA developed twelve recommendations, which were presented to Health Canada. Rather than reading all twelve of them, I will highlight the six that focus on the role of federal, provincial, and territorial governments. For a full list of these recommendations please see pages 20 and 21 of the summary report of cross-country consultation.
First, the federal government should revise the vision and goals document to reflect what was heard during the public consultations. This basic source should be widely promoted and discussed. Adaptations of the document should be produced in formats that are suitable for use by groups of children, teenagers, and parents with low literacy skills. This recommendation puts into action one of the goals: valuing and participating, but participating and acting on what is said.
I am pleased to note we understand Health Canada has recently shared with the federal-provincial-territorial advisory committee on population health an embargoed copy of a new report that summarizes the consultation with communities, governments, and aboriginal groups. We understand there are now eight goals for child health in this report. This is a key outcome, which will be valued by the participants of the consultative process.
Second, federal, provincial, and territorial governments need to agree on a process for moving forward on objective-setting and the application of a conceptual framework. A life stages or transitional approach is recommended, framed by a population-based approach that strives for equal outcome or benefit for all children and youth.
As important as the goals were, and accepted by the public, it was important for us to move from that. They would be meaningless without action.
The federal government should take the lead on development of indicators, criteria, and guidelines that will assist in the next stage of the vision and goals process.
Fourth, the federal government should take the lead in coordinating and ensuring the provision of education and training on parenting and parenting skills. An example is a federal government initiative, the Nobody's Perfect parenting program.
Fifth, recommendations for healthy public policy. First, to facilitate intersectoral planning and action, with a special emphasis on closer links among health, education, social services, and justice. Barriers to action exist where we cannot get along or seem unable to communicate well enough to have these sectors coming together.
Second, conduct an impact analysis on all proposed policies to ascertain their effect on the health and well-being of children, youth, and families. Changes in education will impact on the health of children.
Ensure that a progressive social security system is in place, one that protects and enhances the standard of living of families and poor and modest incomes.
Sixth, the final recommendation I'll review. All levels of government should give priority to meeting the basic needs of aboriginal people and supporting aboriginal people in their efforts to enhance the lives of their children, youth, and families.
The other six recommendations I'll touch on briefly. As I said, they're not any less important than the first six, but the first six have direct impacts on the federal government.
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The other six recommendations outline the importance of roles of non-governmental organizations, particularly in the monitoring of the state of the health of children and the role of schools and the education system. Many of the public in the consultation process saw the value of enhancing the role of schools as being a key element in a community process as a community leader. The comprehensive school health model is exemplary in that regard.
There is the role of the private sector, whether it be in family friendly workplace policies or childcare policies, all the way to getting corporate sponsorship to enhance community initiatives for children. One, Two, Three, Go in Montreal is an excellent example of that kind of an initiative.
There is the role of the health system reform, particularly in understanding the devolution of power, control, and accountability to the community. Again, Brighter Futures is an excellent example of how you look at doing things differently in order to empower the community.
There is the role of employment and the challenge of wealth creation in this country.
Finally, there is the public awareness in education that is key in creating a public will that will sustain our goals for the health of children.
The findings from this community consultation and twelve recommendations support and underscore the importance of child health goals in improving the health of all Canadian children.
I'll touch briefly on the Child Health Record Project, which is a tangible, action-oriented project looking at empowering parents to be able to take back their control over their own child's health.
The Child Health Record Project is a related project. It was undertaken to develop a parent-held prototype of a child health record that would be easy to use, readily available, accessible, and portable. A template was designed to focus on the needs of parents who may be single, culturally or geographically isolated, or with low incomes or limited formal education.
In focus tests with parents, there was a perceived need and significant support for the development of a national parent-held child health record that would be a resource for parents. This support was consistently apparent, including among parents within the at-risk group.
Among health professionals, support for the child health record was apparent but qualified. Some health professionals questioned whether the anticipated health output would justify the cost of producing a national child health record. Others were concerned that it might result in a duplication of effort for health care workers.
The development of a child health record as a resource for parents is considered to be an important step to support and empower parents in their role as care-givers and might lead to better data collection and child health monitoring.
In addition, a child health record can be an important part of health promotion and protection in involving parents more in their child's health.
In summary, CPHA believes strongly in the need for national goals to be set relating to child health, as indicated in the community-level consultations. We believe a strong federal government role is needed to set the goals, with objectives set at the provincial-territorial level, and that implementation should take place at the local level.
CPHA recommends that the federal-provincial-territorial advisory committee on population health should work towards finalizing national goals for child health and that it should coordinate and facilitate the objectives-setting process at the provincial to territorial level.
Thank you very much. I would welcome your questions on this important issue.
The Chairman: Thank you very much.
Do we have any questions?
Mrs. Hayes (Port Moody - Coquitlam): I thank the CPHA for being here today. There are many things I'd like to ask you, and I'll take as much time as I'm given by the chair.
Can you give us some idea of the funding for CPHA in the last while? How much is received from grants from Health Canada? Do you have other sources of support? Do you do projects for other organizations?
I don't want to spend a lot of time on this, so answer as briefly as you can, please.
Ms Stewart: I think Kathryn would be better prepared to answer this question, so I'll pass it to her.
Ms Tregunna: The Canadian Public Health Association receives a significant amount of funding from the federal government in approximately five different departments, including Health Canada, Human Resources Development Canada, and some others.
We have a large international program. We house the Canadian international immunization program. We also house the National AIDS Clearinghouse.
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Within the national programs, we work with our board to identify priority issues and then we talk with Health Canada and other funders to identify potential funding sources. We also undertake some policy development, including an issue paper on the role of public health and health services restructuring, as well as the health impact of social and economic conditions and policies through general funds of the association. And we have membership fees that cover the cost of running the association.
Mrs. Hayes: Is it possible to get a breakdown of those numbers - your operating budget and where the sources of funding come from?
Ms Tregunna: Sure.
Mrs. Hayes: I would appreciate that.
Ms Tregunna: I don't have one with me but I can send it to the committee.
Mrs. Hayes: If possible, maybe we could get them for the last few years. Some of what you've reported to us dates back to 1991, I understand.
Ms Tregunna: Yes.
Mrs. Hayes: This leads into one of my many questions.
You mentioned immunization. This weekend I was reading in the paper that there is an international concern about the effect of immunization on the health of children. We haven't actually mentioned that in our group as far as I know, but - and this is specifically to you since you are involved in that - is it a problem area that we should be looking at as far as the effect on sudden infant death syndrome, for instance, and that kind of thing are concerned? Have you done any work on that?
Ms Tregunna: I think we'll answer that in two areas. At the national level, CPHA has just developed a working group - the group includes representation from the Canadian Paediatric Society, which will be presenting later this morning - to look at the need for a national immunization campaign. We recognize that we have good levels of immunization in Canada, but we can improve those levels. We are not yet meeting some international target levels, so we are working with other NGOs and Health Canada to develop an immunization campaign.
Mrs. Hayes: My question specifically was actually on the danger of immunization. There's been a report out of Japan, for instance, and several other countries where they've curtailed their immunizations and have actually reduced the incidents of deaths in children drastically. Has that been looked at?
Ms Stewart: Absolutely.
I'm from Alberta, where immunization is delivered through the public health service. That's different from the other provinces.
There is continual and ongoing research into the benefits and the risks of immunization. Immunization is not without its risks. I suspect we would be able to gather research very specifically if that needed to be answered. To date, however, the benefits of immunization far outweigh the risks in our country. We have reduced infant mortality because of immunization.
I can appreciate that there are reports - and they are constant - on the risks of immunization. The research community must be able to tackle that and either prove or disprove it. Many of the things that have come to my attention in the last little while typically are a single kind of report and need to be investigated.
There may be some specific answers you need for SIDS, for example. I think that's what you were asking about.
Mrs. Hayes: Specifically related to SIDS, I think Australia and Japan have curtailed their infant immunization program because of real data, real evidence that it is a health risk.
Within your report, you mentioned the effect of poverty as one of your main target areas. I am concerned about the issue of poverty, certainly. Looking at it in isolation, though, gives me some concern. For instance, we could look at some of the poorest regions in Canada - on the east coast, perhaps - where levels of income are low, yet we don't have the crime rates and the disease rates, etc., that are very often related to poverty. Just the other day I was looking at a report on alcoholism and the abuse of alcohol and substance abuse as being such critical factors in the well-being of children and families. Are those things you have looked at? Do you have any data or reflect them in your report anywhere, and specifically on the abuse of alcohol?
Ms Stewart: You're absolutely correct in saying that to look at poverty as a single issue is not the issue. There are many factors that underscore a child's ability to reach his or her potential. Poverty tends to be a catch-all for some of the lifestyle things that are inherent in people who live in misery and disadvantage. Living in misery and disadvantage and feeling hopeless and helpless, the abuse of alcohol is substantial.
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Again, to tackle alcohol and substance abuse as a single issue is not fruitful either, although its effects are devastating, particularly prenatally and in the outcome for that baby. Even if a baby is born healthy but is raised in an atmosphere of alcohol and substance abuse, it is true the outcomes for those children are worse than for ones who are not in those environments, but it must be tackled as a whole. It must be tackled as the environment in which a child lives.
To only tackle substance abuse would not solve the problem. Typically these people don't have work and they don't have meaning in their lives. They are not in caring and supportive environments, and alcohol abuse is simply a symptom of that. But yes, it has devastating effects on children.
Mrs. Hayes: I certainly wouldn't want to say everyone who is poor has an alcohol problem, which is sort of what it sounded as though you were saying -
Ms Stewart: Absolutely not.
Mrs. Hayes: - but very often families that have alcohol abuse are within a poverty syndrome. It certainly goes that way.
I have another comment. In the public review of your report, there certainly was some concern - and it's reflected in this document you gave us - about the lack of emphasis on the importance of family within that document. I find that significant. You have a chapter title here that says ``We Cannot Ignore the Family''. I find that a backwards way of saying it. To me, family should be the most important thing. It's almost as though you've been dragged into saying ``Oops! We'd better not forget something''. The mindset of even that title is very interesting.
Also included in that mindset is.... Your comment was that a large concern of people is the diversity of family types and the fact that it had been limited within the report. The first sentence in your review indicated that in fact emphasis had not been placed on family within a child's life and in the development process of a child. Certainly this other is an issue, and it is an issue with this particular government, I know.
When people say they're concerned about the diversity of family types, does that reflect the importance of single-parent families? I would concur that single-parent families are under stress within our economic situation for sure. Are you saying there's a wide concern beyond that on the definition of family? Or is it to include these basic and very often struggling units of, say, a single parent trying to bring up children?
Ms Stewart: What is the context of that?
Mrs. Hayes: Yes, what is the context of that?
In relation to that, this document also mentions there are somewhere specific suggestions for editing and changes to the original report. Is that available to this committee? Within those specific suggestions and changes and perhaps the sources of those suggestions and changes, maybe we can get a better flavour of, for instance, what you said about family types and the definition of that. Maybe you could answer that.
Ms Stewart: Sure, you bet.
I'll start with the context of why that even arose as a consultation item from the public. There has been a healthy struggle between the paramountcy of the child versus the family having the ultimate rights for their children. I call it healthy because I think all people in the consultative process are very aware of where children are nurtured; they're nurtured within families. However, when families break down or do not provide the basic necessities for children, we need to also have regard for the rights of the children as themselves.
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So that was part of the struggle and certainly came out in the public consultations on where people sat in understanding the importance of the child, but valuing children for who they are.
The discussion about how important families are was very much in the context of what that child defines as having been most important to him or her in their nurturing and support. Typically that will be their immediate family. Sometimes it is not. Sometimes it is aunts and uncles. Sometimes it is grandparents. Sometimes it is people who are not relatives. The definition of family needs to be as broad as we can keep it to ensure they are considered as valuable to the nurturing of that child.
I don't think the emphasis was only on a single-parent family. It is recognized that those are family types, but more importantly, it was looking at the diversity and the breadth of a family definition in how a child is raised and can be raised in our society. To only put that on mother and father would limit the possibilities for the strength we need to bring in support of our children. That was the context of that discussion.
The Chairman: You're out of time. You're over time, as a matter of fact, but it was interesting. We might get back to you.
Madeleine.
[Translation]
Mrs. Dalphond-Guiral: Of course, children's health concerns everyone. On the other hand, we must take into account that for the last few years, we have been living in a context of major budgetary restrictions. Health, like education, is above all a matter of provincial jurisdiction. Even if we have the most extraordinary objectives, on which everybody agrees, it might not be realistic to think that those objectives will be achieved within the next ten years. In that context, how can we manage to give priority to the most urgent needs?
Everybody admits that poverty exists, but there are more and more poor families and more and more poor women. It is very well known that poverty leads parents to insecurity, and therefore brings them in a sort of vicious cycle. When a child feels insecure, he ends up falling sick. Being ill becomes for him a means by which he can draw attention. What do we do then? Do you have any idea?
I read somewhere that we should devolve to communities as many responsibilities as possible, along with the necessary resources. The problem is that responsibilities are being transfered without the necessary resources, because resources are being cut. So, I have got the impression that we are going nowhere. Am I wrong to think that way?
[English]
Ms Stewart: You've hit on a very critical issue.
It is my experience in Alberta that we are in the middle of health reform where we are struggling with budget cuts and reduced resources. But that is also in the context of trying to understand how you will better resource communities to be able to take hold and be responsible, to do what they do best.
I am of the opinion that it is very important not to think you will make this better by continuing in the way we have in the past. To professionalize and institutionalize health has not made great gains in the last little while.
The importance of devolving control and accountability to the community is paramount. That does not necessarily mean you have to have the same level of resource. Access to resources is important.
I think about what Fraser Mustard and Dan Offord are saying in forums across the country, that wealth creation is important and it has to be at the community level. But that doesn't mean professionals walk into a community and do things to the community.
The communities that are making things happen are those where there is the creation of public will. What does that cost? I don't know. But the creation of public will is where the community takes on the well-being of children as part of what they do.
The communities that are doing well have leadership within their communities to sustain these efforts. You cannot resource a community in non-sustainable ways. Typically, that is putting in service. It is non-sustainable if you do not have community leadership and the public will to do those things in communities for children.
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The importance of the corporate sector in funnelling funds into such projects, outside of the public dollar - the corporate dollar has to come face to face with this as an issue. Why? Because children are the resource for our economic stability in the future.
I think I mentioned One, Two, Three, Go in Montreal and Success by Six in Edmonton. These are sustainable projects that are engaging the corporate community, saying you must be involved, because you will invest in children; you will invest because it makes good sense for you to invest.
Those are the kinds of resources that have to come to bear at a community base, because that's where you will get the most innovation, the most creativity, and the most solutions that make sense.
I think where we have gone wrong is in saying, here are the solutions and here are the answers. We do not consult; we do not communicate with the users or the people who have the problem, who typically also have the solution.
It is taking risks right now. In my province it is taking money out of institutional sectors and putting it into the community sector. It is not new money; it is money that exists, being taken out and put back in. Yes, it is risky; yes, we need to have a length of time to evaluate the return on your investment for children, but it is clear to me that the way we have done it is not making gains for children. It is also clear to me that we have limited resources, and within those limited resources you need to exchange where it was put to another place.
That the community must own the problems and come up with a solution, community leadership, the ability to evolve, to be able to step lightly from one initiative to another, to look at the gains you're making, to be able to switch gears, to be able to make the case for outcomes for children - these things are all really important. Understand what outcomes you want, and look at creative ways to reach them.
These ways will typically not be the ones I dream up as the manager of community health services. It will be the community that defines them. You're right; we have limited resources, but you can be challenged to live within those resources if you devolve control and accountability.
Ms Tregunna: I think there's also a recognition that within the community health or public health venue we clearly understand and value work from the community up. I think there's also a need, though, for a framework or direction to be set at the provincial level, in terms of objectives that are attainable and measurable, and, as you said at the beginning, not to have something that's so high that no one can reach it and it makes us wonder why we're even trying, and for goals and objectives that can be identified.
You asked earlier too about how we know what our priorities should be when there are just so many issues - poverty and everything else. We have some good statistics that can help us build that understanding. We're beginning to develop indicators that can help us see where we could get the most advantage for children's healthy development, and we also - moving up to the next stage, with federal leadership - can look at some overall goals for all Canadian children.
So it's a partnership between local development and initiative, and understanding the resources and the needs within a specific community, and the need at the other side, of having a broader framework to develop the initiatives to move forward.
Ms Stewart: Some of that research would look at the resiliency of children - what are those characteristics, and how you would build them, not only in children, but in families and communities. As Kathryn has said, the research is fairly clear: social competency, ability to problem-solve, problem-solving skills for children, autonomy, a good sense of self and a sense of purpose in a future, an environment of caring and support, high expectations set....
If you look into the family histories of children who live in poverty and succeed, you'll find they grew up within families who said, despite this environment, you can be the best that you can be, and those children pull themselves up and out.
Finally, children should be encouraged to participate in their own well-being. These are the characteristics of an environment that creates resiliency in children. As you'll note, this is not ``doing for''; this is understanding those resiliency skills and systematically building them in children, empowering parents with education and support to be able to manage that with their children. Those are the kinds of priorities....
The Chairman: All right, we're out of time. What you have to say is most interesting. Obviously you know your file well;, that's why you're here, and we hope this will be the beginning of a beautiful relationship. We'll be in touch with you as our study progresses. We thank you for coming. I realize that at least one of you has travelled from Edmonton, and Kathryn, you're from here, aren't you?
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Ms Tregunna: Yes.
The Chairman: While the timeframe here was very short, we welcome the opportunity to get to know you as part of our endeavour to do a good study.
We invite the representatives of the Canadian Paediatric Association to the table for the next segment.
While the transition is taking place, just let me have the attention of the committee for a moment. There's very likely going to be a vote. The bells will ring just after 10 a.m. It will be the half-hour bell. The vote will come around 10:35 or so. We have a third set of witnesses, some of whom have come from out of town today. I'd prefer not to send them home without being heard.
I suggest that three of us stay here during the vote and hear the evidence. I'm prepared to be one of them. It's likely a procedural vote, so if three of you, two of you including at least one from the opposition.... The rules require three, including one from the opposition. Is that right?
Yes, it is. Would you consider that in the next few minutes? If you have to check with your whips, do so.
We welcome the Canadian Paediatric Association. Would whoever is in charge just start talking? Introduce your people and say what you have to say, but give us some time to ask you some questions, please.
Dr. Frank Friesen (President, Canadian Paediatric Society): Mr. Chairman and honourable members, I'm Frank Friesen, and I'm president of the Canadian Paediatric Society. I'm here with Dr. Pierre Beaudry, our president-elect; Dr. John Holland, who represents the university department heads on CPS; and Dr. Victor Marchessault, our executive vice-president.
I apologize to the committee that due to the short nature of our forewarning for this we don't have a full summary of our presentation and its translation.
Thank you for giving the Canadian Paediatric Society the opportunity to address this committee on the determinants impacting on the health of all children in Canada and of aboriginal children in particular.
To achieve their greatest potential children must have their physical, nutritional, housing, clothing, immunization and emotional needs met as well as their need for a sense of positive worth and a spiritual sense of community.
Many of today's social problems are affecting children at a very early age. Child abuse, violence, youth gangs and crime, underemployment and financial constraints are examples of this. A visionary universal approach is required to solve this. Education is the key to understanding and understanding is the beginning of a solution.
In the past three years programs under the Brighter Futures initiative of the federal government have made a difference in the lives of Canadian children. The CPS, with Brighter Futures support, developed and disseminated ``Well Beings'' and ``Little Well Beings'', quality care guidelines for licensed and day care centres. This resource has since been adopted as part of the education system across Canada.
Currently, with the federal government's support, we are developing a guide for health care providers for the care of immigrant children, including the international adoptee. This information has long been in demand. This type of funded research must continue to deal with the many problems facing us today and in the future.
The CPS, in its national health goals and objectives for Canadian children and youth, urges the federal government to make an investment in Canada's children. This is a long-term investment that some estimate would save $7 for every $1 spent. Canadian children and families need such an investment in primary prevention.
Folic acid supplementation, prevention of low birth weight in pre-term infants, breastfeeding counselling, genetic screening, early discharge follow-up, nutrition, well baby care, sudden infant death syndrome, standardization and accessibility of patient records, child immunization, injury prevention, and smoking issues are but a few of the areas in which we need further work and education. The Canadian Paediatric Society is ready to work with the federal government and all other organizations whose mandate is the child's best interest.
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As I'm sure you're aware, folic acid supplementation to a minimum of 0.4 milligrams per day has been shown to reduce the incidence of spina bifida, or neural tube defects, by 75%. It will also reduce the incidence of Down's syndrome, congenital heart disease, and limb reduction anomalies. In order to be effective, it must be taken at least one month before conception and for at least three months post-conception. At present, Health Canada recommendations suggest eating folic-rich foods - it is a nearly impossible task to consume the required amount - and taking a supplement.
As 50% of pregnancies in Canada are unplanned, these recommendations, I believe, are untenable. The CPS believes foodstuff fortification with folic acid, similar to that done with vitamin D and vitamin A, is the most effective means to accomplish this. We recommend a pilot study be done to assess the efficacy of food fortification, with a component for assessing other possible adverse effects.
Since recommending this pilot project to the Minister of Health in July 1994 and having it re-discussed at a Health Canada workshop in March 1995...this project has been held up by an internal disagreement within the federal government. During this time, approximately 18 months, roughly 450 children in Canada have been born with neural tube defects. This represents a medical cost of approximately $30 million over their lifetimes. This is exclusive of their personal suffering, loss of earning potential, social service costs, etc. We must have a means of resolving disagreements within the bureaucracy to get on with important projects that are both cost-effective and indeed life-saving.
I'd like to address early discharge. With the ever-decreasing health funding to the provinces, ways of cutting hospital costs are being proposed and implemented. The early discharge of the healthy mother and newborn is one such proposal. This early discharge...which is often less than 24 hours of age...does not allow time for the psycho-social assessment of the family or the establishment of breast-feeding for the mother and infant. Increased morbidity from dehydration and jaundice and increased incidence of readmissions to hospital are the result.
The CPS believes these discharges should not be implemented until there is an established follow-up program in the home to recognize problems in the home and provide ongoing educational support to parents. The time of discharge must remain a decision between the mother - the informed consumer - and her physician.
About genetic screening, it is done in all provinces. It is most successful in the prevention of phenylketonaria and hypothyroidism, both of which lead to mental retardation and very excessive health care costs. However, there is no standard mechanism to ensure that all newborns across Canada have been screened, and there's no standardization of reporting to the physician. We have cases on record in which screens were either not done in hospital or lost in transportation...whether that's the mail or what.... The physician, expecting it's been done and expecting a no report, or not receiving a report as being appropriate, has made incorrect assumptions about the health of the child and the diagnosis, with long-term detriment to the child; i.e., mental retardation.
With increasingly early discharges, these screenings will have to be repeated after discharge from hospital, and ideally should be done in the home. Also, with an increase in home birthing, there must be assurance that these children are also screened. The CPS recommends a standardized mechanism whereby all infants will be checked to ensure screening was done and the results will be forwarded to the primary-care individual.
Dr. Pierre Beaudry (President-Elect, Canadian Paediatric Society): We've divided the presentation. You asked us to give in the presentation examples of activities we do with Health Canada. We've been known over the years to participate very closely with Health Canada and to do a certain number of publications related to that in certain fields.
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The words ``fetal alcohol'' were brought up before. Alcohol problems were brought up earlier this morning. We are pleased to see that there is a concern and that last year, in 1994, 20 organizations came together, including Health Canada, and that the problem of fetal alcohol syndrome, as a disease of the young child who was born of a mother who has ingested too much alcohol, and fetal alcohol effects on the child have been looked at and these data are being submitted and will be published early in 1996 by Health Canada, with the cooperation of other groups.
This is a common approach to this problem. There's a need for dissemination of this information to large groups of people.
Smoking and problems of prevention of low birth weight in pre-term babies: There's an effort on the part of the Government of Canada, as expounded by the Minister of Health last year, to improve nutrition of pregnant mothers. That will prevent some undernutrition.
We mustn't forget, and we would like to highlight, that the greatest cause of malnutrition and low birth weight is smoking. This is something that we know and has been proven to be so. That needs to be emphasized, and we have to find strategies to get that across to the public at large.
Nutrition is a subject that is always of interest to various people. We hear a considerable amount of information about high-fat diets. It's rather interesting that, while you do not want high lipid contents in the adult because of their side-effects, in the growing child this might be a beneficial effect and we might need it.
The Canadian Paediatric Society, with Health Canada, has produced a document, which has been presented to you and is deposited with the documents we left with you today, on what the optimal levels of fat should be in the diet of a child.
We are concerned about anemia in childhood. There are concerns that trying to detect anemia in early childhood might not be all that easy to do, but that if anemia, lack of iron in the blood, develops, it will cause both mental and psycho-motor development retardation. We are very much in favour of fortified cereals and, if children are taking formula, fortified formulas.
The word ``immunization'' came up earlier this morning. Of course we are very much in favour of immunization. There are concerns, and these are brought up on a regular basis. These problems of the side-effects of immunizations are real. On the other hand, it has to be understood that some myths are out in the field.
We are just undertaking a major piece of work to show the hard data, whereby there is no doubt that immunization is beneficial and it has to continue and we cannot relent on the continuing of immunization programs.
If one looks at a very recent vaccine, the hemophilus influenzae type b, and the decrease in meningitis, and how much cost we save by the introduction of hemophilus influenzae type b vaccine and how much suffering we have prevented, one doesn't have to go very far to be very much impressed with it.
We are very concerned about the patient record. You've heard of that before, and we come on the same tangent as the public health group: we still believe that somehow or other there has to be some kind of record for the child on a national basis so that - we're a mobile population - people will have access to at least immunizations.
The growth and development of children have to be recorded. In this day and age, there must be a way, a smart card or a central registry, where that could be made available and could be accessed easily by the care-givers - not only physicians - to know what immunization children have had so they will not get exposed to unnecessary re-immunizations. The patient care record is something about which we are very concerned. We come close to this.
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If we look at the older child, we are concerned about injury prevention. We have to remind ourselves that injury is the greatest killer of children beyond two years of age. It is the greatest cause of death. We have to be vigilant to remind ourselves on an ongoing basis of all the safety measures that have to be taken.
Some areas require legislation, and where legislation is needed, we will request it. An example of that in the recent past that has been effective is child-proof lighters and non-flammable sleepwear, where there is now legislation that is being effective, and that is saving dollars.
Information is important, and when I dream in technicolor, which happens sometime, I see a coalition of Health Canada and groups like our own getting on the Internet and putting out information that people can access. We have to get information to the people that is easily available, and it seems that the information highway would be the place where we could give parents and families up-to-date knowledge so that they can get a handle on their own health and pressure the health-giver to give the appropriate care. When I dream, I dream in technicolor, and I'm sure we'll find a way to put that information on the Internet.
Dr. John Holland (Member, Canadian Paediatric Society): My name is Jack Holland and I am the chair of paediatrics at McMaster. I am here representing all the 16 medical schools across the country from the redwood forest to the Gulf Stream waters.
I would like to highlight a few of the presentations made not only by the previous speakers at this table but also by the CPHA in which it is very clear that a secure and positive experience during the first three years of life set the road map for future development. I think that above anything else we have to drive that point home.
A government can probably make its best investment by looking at the needs of children and their families in the first three years of life. The key ingredients surround the social environment of the child and his or her mother during that time period. Both Dr. Friesen and Dr. Beaudry have highlighted some specific interventions that will probably make a huge difference in the long run.
Why am I here? I'm here to convince you that in terms of structure and communication there is a network available that will get the job done. The network is really a series of forward-thinking individuals who are available to help develop and to implement policy, a network that puts the interests of children and families before the interests of its individual members and a network that, frankly, will still be here when governments have come and gone.
How would this be done? To do this, I would like to describe - and I'll do it as quickly as I can - the role of universities, the Canadian Paediatric Society, hospitals and communities in effecting health care and changes to health care.
Let's talk about universities. I'm going to talk for the most part about my own university, but this is readily applicable to universities across the country. We have a primary role in educating the next generation of health care-givers. Think about that. We're educating the next generation of medical students, nurses, physiotherapists and health care workers for the future, and we have to deal with them in a way that they will recognize the needs of the future. We have a very important role.
We have to establish research priorities within our own respective centres. We have to steer that research in a direction that will yield something meaningful to child health, to children and their families. We have to work with others in policy development and in child advocacy.
Two clear examples include the recent gun control laws, which the Canadian Paediatric Society, the Canadian chairs and others helped push through. We were involved with the smoking legislation and the legislation that was passed, wisely, on seat belt legislation. That is just an example of a few of the things where we have worked together to achieve something that will be meaningful in the long run.
As chiefs of departments of our respective base hospitals, we also have a role. We have a role from across the entire country, from St. John's, Newfoundland, to British Columbia's Children's Hospital. We work with hospital-based child health providers and planners to keep the needs of children front and centre at a time when the country and the provinces are undergoing great upheaval, downsizing and economic constraints. At the same time, we cannot forget the special needs of children with complex, tertiary-care illnesses such as heart disease or severe neurological disease that require specialized tertiary-care services. We are there for them.
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We also work with our communities and our district health councils to effect change that is necessary; change that recognizes the problems that our country faces; change that ensures that planning for the future is based on the best information available; change that is conducted in a manner that is thoughtful and coordinated and puts children and disadvantaged families in a context that is appropriate.
Frankly, we also think our role is to maintain a positive and constructive attitude and approach to health care at a time when people do not feel positive.
As examples of these, at my own centre we're doing research on children with disabilities. That research can be as simple as providing measures of satisfaction of parents in the process, or it can be as complex as looking at the genetic ideology of children with disabilities. We can look at the research and ideology and prevention of child abuse. The previous speakers have made reference to Dan Offord and Fraser Mustard, who have again made similar overtures about looking at population health and things that matter.
We're looking at the research of health, economics and early patient discharge, the outcome of intensive treatment of children with lymphatic leukemia, and the quality of life for the premature infant, not just one day later but one, five or ten years later. Those are all ongoing.
We're looking at a university medical curriculum that incorporates within it the expertise of nurses, physiotherapists and biostatisticians to create a learning matrix that fosters lifelong learning, that fosters a population approach to health, that fosters problem solving, and that fosters the use of other services within the health care system, such as the establishment of midwifery centres, of nurses with specific needs and skills such as neonatal and intensive care.
We've fostered university-community linkages and rationalizing regionally, pointing out the importance of maintaining a good educational infrastructure to maintain the best quality research and clinical service. An example of this is the Health of the Public project. Only one university in Canada is involved so far, and it's funded by the Rockefeller Institute and the Pew foundation. It recognizes the problems of the community and the expertise of the universities and brings them together in a meaningful way.
Just two examples of the fifteen that have been fostered in the last two years include research that involves schools, school children and youth against violence, and organizations that bring schools, universities and methodologists together to get the job done. Dispute resolution and divorce court disputes between parents over their children are also areas where universities and communities have come together to try to make a difference.
Over the last five years, the Canadian Paediatric Society has made a special effort of establishing goal standards, of establishing benchmarks, of trying to write position statements that can be used by pediatricians-at-large across the country and those who work both nationally and internationally, both in Europe and around the world, and of looking at the best outcomes and making them meaningful and translating them into action for Canadian children.
My bottom line is that there is an infrastructure. There is a network of committed individuals who have been here longer than this government has been here. They are willing to work with the government to develop and implement policy. Use us to your best advantage.
Thank you.
The Chairman: Thank you, Dr. Holland.
Dr. Patry is the first intervener. Go ahead, sir.
[Translation]
Mr. Patry (Pierrefonds - Dollard): Good morning. I apologize for being late, but our committee hearings start at 8 o'clock on Tuesday morning. It is very early.
In your statement on national health goals and objectives for Canadian children and youth, you mentionned, on page 13, that "high quality, affordable child care is a necessity if our children are to receive the full support they require to flourish as adults".
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On page 17, you also recommended the adoption of a "national program of high-quality, accessible day care". In my mind, children who are placed in day care centres have many more infections - upper respiratory track or ear infections - than those who are not, and consequently are given many more antibiotics than other children. Those antibiotics may affect their immune system in the long run.
Could any other kind of parental support contribute to prevent those health problems - physical as well as emotional - in children?
[English]
Dr. Friesen: The Canadian Paediatric Society favours day care, but it does not necessarily favour completely publicly funded day care.
Why do we have day care? I don't believe we have day care to have better developed children. I think any capable mother who's interested, warm, and affectionate with her child, whatever level of poverty she may be at, can stimulate her child appropriately. I think we have day care because it's an economic necessity in today's world. You cannot get by on just one salary in today's society.
Now, the question was about an increase in infectious diseases related to day care. Certainly I think that's true. As a primary care-giver I see lots of children with day care illnesses, and most of this is related to large day care centres, i.e. greater than five children, and it is much less in a private day care setting.
I don't think there's any evidence that these recurrent illnesses have a detrimental effect on their immune system. Perhaps my infectious disease colleagues could comment more on that. Certainly they do have more use of antibiotics, which may cause an increase in the incidence of antibiotic resistance. I think the society through its statements is trying to make better use of antibiotics for children despite the fact that consumers, informed as they are, demand an antibiotic for every cold and despite the fact that some physicians indeed give an antibiotic for every cold.
[Translation]
Dr. Victor Marchessault (Executive Vice-President, Canadian Paediatric Society):Mr. Patry, I think that what you have read about our goals and objectives does not exclude family day care homes, which we also recommend.
In our paper, we recommended that caretakers in large day care centres be highly qualified. But it seems more and more obvious, from what you said, that the absence of grandparents or of local resources most often leads to the admission of the child in subsidized day care centres.
Our main project, for the next two years, will be to study the use of antibiotics, because abuses in that area are a source of great concern. Although almost all children placed in day care centres have respiratory track infections, the need for those antibiotics is absolutely questionable in such cases.
Besides, it has been demonstrated that children who are looked after by family friends are as well-balanced when they reach adulthood as other children placed in licensed day care centres.
Mr. Patry: May I ask you a question concerning Health Canada programs? On page 16 of your document, you recommended a number of national policies aimed at improving children's safety and health.
At the prenatal stage, you proposed the organization of campaigns to promote good nutrition and to prevent smoking, alcohol, drugs, STD, AIDS and unwanted pregnancy. Health Canada already offers a good number of those programs.
Do you think Health Canada is meeting the objectives you are aiming at? If yes, should we do otherwise, and what should be done if those objectives are not met by Health Canada's campaigns?
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Dr. Marchessault: Based at least on our joint experience concerning those programs, we are in a position to say that Health Canada has clearly met the objectives that we had set ourselves.
The best example of that is the document which we prepared for large day care centres. In that document, we described all the needs of children and their solutions. It is like an encyclopaedia presenting everything that has to be done in a day care centre.
Also, again with the support of Health Canada and of some private enterprises, we have published a book on family day care services, copy of which I left with the clerk.
This is an abridged version of the first volume, which comprises two books, which by the way has been published in Sélection du Reader's Digest.
Another example concerns the treatment of sexually transmitted diseases. The Canadian Paediatric Society and the LCDC were the first in North America to publish a practical document for first line caregivers, designed to help them in the diagnosis and the treatment of sexually transmitted diseases.
In some way, it was a preview, because the CDCs in the United States endorsed our documents and adapted them to their own population, who do not have access to free care services like we do in Canada.
Much remains to be done. We are continuously engaged in joint programs. One of the most serious might interest Mrs. Hayes who was talking earlier about immunization.
Following pressures exerted by concerned parents regarding the reported effects of vaccines, we decided to set up a monitoring system in ten paediatric hospitals who account for 85% of all children's admissions in Canada. That system has been in place for the last five years, and we are now in a position to observe that, like we had presumed, abnormal reactions from vaccines are no more frequent than we expected. Through that system, any admission suspected to be related to an earlier immunization is methodically monitored.
Mrs. Hayes mentionned that much can be read about the detrimental effects of vaccines. If we read only bad news about vaccines, it is because there are no scientific books to reassure people concerning the advantages of immunization as opposed to the disadvantages of having no vaccines at all.
I am one of the few in here to be old enough to have seen those former polio epidemics we had in 1959. Thanks to immunization, those epidemics are now things of the past. Even younger physicians say: "Why should we vaccinate people against diseases which are not severe?" Of course, if those diseases are not severe, it is simply because they are prevented.
Therefore, we have established a protocol which will allow us to publish a non-scientific document. Facts will be based on science, but the document will be written in a language easily understandable by eight-grade students. It will therefore be accessible to ordinary people. We are always talking of evidence-based medicine. We will show that sudden infant death syndrome and neurologic problems associated with immunization are not necessarily the result of immunization.
The Chairman: Thank you, doctor Marchessault.
[English]
We're under the gun here in terms of the bell. For the information of members, the vote will take place in exactly twenty minutes from now. What I'd like to do is briefly bring our next set of witnesses to the table, acknowledge their presence, and have them come back in February.
Yes, Sharon?
Mrs. Hayes: Mr. Chairman, could I ask that perhaps we could submit brief questions to be answered in written form by the witnesses, having not had an opportunity to ask them?
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The Chairman: Sharon had some questions and I regret I had to send her a signal that we couldn't hear her right now because of the constraints of time. I wanted to also ask Dr. Friesen something, and maybe he can give me this answer separately, too.
You made some mysterious allusion to great confrontations within the federal bureaucracy. We'd like to have some of the dirt on that one. There's not time for it now, but maybe you could indicate to one of the staff or in writing, whichever you like, what you had in mind there. If there's something we can do to address it, we will.
Dr. Friesen: I think some of that is in your manual.
The Chairman: Okay.
I want to thank the Paediatric Society.
I call the people from Campaign 2000 to the table, please.
We're going to hear these people for two or three minutes and then we're going to break for the vote. They want to come back in February anyway.
Good morning. We appreciate the fact that you've come, but I think the clerk has explained to you the problem we have. Our first duty is to be in the House, and the bells are calling us. We understand, however, that some of you have travelled from Toronto, and I understand you indicated to the clerk that you wouldn't be too upset if you had to come back again when the House reconvenes. Is that correct?
Ms Rosemarie Popham (Chair, Campaign 2000): Our goal is to have a worthwhile exchange, and I understand that would not be possible this morning. So I think to come back in February would probably be a better plan.
The Chairman: Sure. Just identify yourself for the record and introduce your colleagues, please.
Ms Popham: My name is Rosemarie Popham and I'm the coordinator of Campaign 2000. With me this morning are two of the other partners from Campaign 2000, Noëlle-Dominique Willems from the Child Poverty Action Group and Sharon Chisholm from the Canadian Housing Renewal Association.
The Chairman: We're glad to have all three of you. We'd like to spend more time with you, but it's going to have to be in February.
Ms Popham: We'll look forward to a date.
The Chairman: Have a Merry Christmas.
Ms Popham: Thank you.
The Chairman: The meeting is adjourned.